Gallstones pt.2

Question 1

What is most common complication of gallstones?

Answer 1

Biliary colic

Question 2

What is biliary colic and what causes it?

Answer 2

• It refers to the acute, painful spasm of the gallbladder wall due to a gallstone temporarily blocking the neck of the gallbladder, cystic duct or common bile duct
• With the flow of bile being obstructed, the pressure increases, so the gallbladder contracts to try and push the bile past the gallstone, further increasing the pressure against the gallbladder wall, resulting in visceral pain

Question 3

What tends to precede biliary colic symptoms?

Answer 3

Tends to be preceded by a fatty meal

Question 4

Clinical features of biliary colic?

Answer 4

• The pain associated with biliary colic tends to be a sudden onset, severe, colicky pain, usually in the right upper quadrant.
• Symptomatic patients with biliary “colic” experience excruciating pain, although this name is a misnomer, as the pain is usually constant, not colicky.
• Pain often follows a fatty meal that induces gallbladder contraction, which presses a stone against the gall bladder outlet, leading to increased pressure and eventually pain.
• This pain may also radiate to the epigastric region, right shoulder, and interscapular region.
• Patients are usually otherwise systemically well but may display voluntary guarding.

Question 5

Investigations in biliary colic

Answer 5

• Blood tests are usually normal as biliary colic does not usually result in changes in inflammatory markers or liver function tests.6
• The gold standard investigation to visualise gallstones is an abdominal ultrasound.

Question 6

Management of biliary colic

Answer 6

• For patients with milder symptoms, simple analgesia and lifestyle changes can aid with symptom management, including weight loss, a low-fat diet, and avoiding triggers such as fatty meals.1
• However, after an episode of biliary colic, most patients will experience further episodes, with an estimated 60% of patients experiencing recurrent pain within two years of the initial attack.3
• Therefore, for patients suffering from recurrent attacks, a referral for an elective laparoscopic cholecystectomy should be made

Question 7

What is cholecystitis caused by?

Answer 7

• Acute cholecystitis is precipitated in 90% of cases by obstruction of the neck of the gallbladder or the cystic duct by a stone
• Cholecystitis without gallstones (acalculous cholecystitis) may also occur in severely ill patients and accounts for the remaining 10% of cases

Question 8

Clinical features of acute cholecystitis

Answer 8

• Patients with acute cholecystitis report much more constant pain in the right upper quadrant compared to the collicy type of pain experience in biliary colic, which may radiate to the epigastrium and/or the right shoulder and interscapular region.
• The pain is often worse on deep inspiration, sometimes halting their inspiration (inspiratory catch) due to pain
• Unlike with biliary colic, patients tend to be systemically unwell and may have a fever, nausea and vomiting.
• Most patients are free of jaundice, ; the presence of hyperbilirubinemia suggests obstruction of the common bile duct.

Question 9

Investigations in acute cholecystitis

Answer 9

• In acute cholecystitis, inflammatory markers (such as the white cell count and CRP) are usually raised.
• Liver function tests may be normal or show a raised bilirubin, ALP, ALT, and GGT
• Like biliary colic, ultrasound is the gold standard for diagnosis, which helps to detect any signs of gallstones and associated gallbladder wall inflammation.
• However, when this is not available, or when sepsis is suspected, a CT scan with contrast or MRI should be requested, which can help to rule out other intra-abdominal pathologies, gangrenous cholecystitis and any perforations

Question 10

Management of acute cholecystitis

Answer 10

• As most patients are usually systemically unwell, acute cholecystitis normally requires hospital admission for oral or IV antibiotics, depending on what the patient can tolerate.
• Although symptoms can improve with antibiotics, most patients will undertake a laparoscopic cholecystectomy within seven days of diagnosis.
• For patients who are critically unwell or unable to tolerate general anaesthesia (e.g. due to frailty or significant comorbidity), a percutaneous cholecystostomy is an alternative option

Question 11

What is acute cholangitis?

Answer 11

Acute inflammation/infection of the biliary tree

Question 12

What causes acute cholangitis?

Answer 12

• Acute cholangitis occurs when there is an obstruction of the biliary tree, which is usually secondary to an impacted gallstone, strictures or as a complication of endoscopic retrograde cholangiopancreatography (ERCP).
• Bile stasis provides bacteria (usually gram-negative and anaerobic bacteria) with the ideal conditions to multiply. As time progresses, this infection tends to ascend proximally towards the liver.

Question 13

Clinical features of acute cholangitis

Answer 13

• Ascending cholangitis should be suspected in patients who are jaundiced and who appear systemically unwell.
• Patients may present with pale stools and dark urine and may also present with concurrent sepsis
• A triad of symptoms, called Charcot’s triad, is often seen:
  Right upper quadrant pain
  Jaundice
  Fever

Question 14

Investigations in acute cholangitis

Answer 14

• Blood tests will typically show an elevated white cell count and raised CRP.
• As many patients are septic, patients may also have thrombocytopenia, coagulopathies and a raised lactate.
• Liver function tests will generally show an obstructive jaundice picture (raised ALP and bilirubin).
• Gamma-GT will sometimes be mildly raised, and ALT and AST may also be mildly elevated.
• Ultrasound is often used as a first line to look for a dilated bile duct. If this is negative, an abdominal CT with IV contrast should be requested.
• The gold standard for diagnosing ascending cholangitis is with ERCP.
• However, as this procedure is invasive, magnetic resonance cholangiopancreatography (MRCP) is often preferred

Question 15

Management of acute cholangitis

Answer 15

• Many patients will be septic, so prompt administration of broad-spectrum IV antibiotics and IV fluids is essential, as well as any correction of any electrolyte or coagulation disturbances.
• ERCP is diagnostic and therapeutic and is used to decompress the biliary tree urgently.
• Percutaneous trans-hepatic cholangiography (PTC) is the second line for patients where this is unsuitable or if ERCP has been unsuccessful.

Question 16

How many patients with gallstones will be asymptomatic?

Answer 16

Gallstones may be present for decades before symptoms develop, and 70% to 80% of patients remain asymptomatic throughout their lives

Question 17

What causes acute aclculous cholecystitis?

Answer 17

• thought to result from ischemia
• Contributing factors may include inflammation and edema of the wall (compromising blood flow) and gallbladder stasis due to accumulation of microcrystals of cholesterol (biliary sludge), viscous bile, and mucus, causing cystic duct obstruction in the absence of stones.
• It usually occurs in acutely ill patients who are hospitalized for unrelated conditions. Risk factors for acute acalculous cholecystitis include: (1) sepsis with hypotension and multisystem organ failure; (2) immunosuppression; (3) major trauma and burns; (4) diabetes mellitus; and (5) infections.

Question 18

Pathophysiology of acute cholecystitis

Answer 18

• Acute calculous cholecystitis results from chemical irritation and inflammation of a gallbladder obstructed by stones.
• The action of mucosal phospholipases hydrolyzes luminal lecithins to toxic lysolecithins.
• The normally protective glycoprotein mucus layer is disrupted, exposing the mucosal epithelium to the direct detergent action of bile salts.
• Prostaglandins released within the wall of the distended gallbladder contribute to mucosal and mural inflammation; distention and increased intraluminal pressure compromise blood flow to the mucosa.
• These events initially occur in the absence of bacterial infection, but later in the course bacterial infection may be superimposed and exacerbate the inflammatory process.

Question 19

Which is more dangerous, acalculous or calculous cholecystitis?

Answer 19

• Clinical symptoms of acute acalculous cholecystitis tend to be more insidious, since they are obscured by the underlying conditions precipitating the attack.
• A higher proportion of patients have no symptoms referable to the gallbladder; diagnosis therefore rests on a high index of suspicion.
• In the severely ill patient, early recognition of the condition is crucial, since failure to do so almost ensures a fatal outcome.
• As a result of either delay in diagnosis or the disease itself, the incidence of gangrene and perforation is much higher in acalculous cholecystitis than in calculous cholecystitis.
• In rare instances, primary bacterial infection by agents such as S. typhi and staphylococci can give rise to acute acalculous cholecystitis.
• A more indolent form of acute acalculous cholecystitis may occur in the setting of systemic vasculitis, severe atherosclerotic ischemic disease in the elderly, AIDS (usually related to Cryptosporidium infection), or ascending biliary tract infection.

Question 20

What is biliary tract disease attributed to?

Answer 20

More than 95% of biliary tract disease is attributable to gallstones